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Operating Room Resuscitations

Mike Smertka medic0947969 at yahoo.com
Fri Feb 1 23:00:55 GMT 2008


  I didn't mean to imply that a 24 hour ATLS class was going to make anyone an expert at surgical trauma care. You echo my point that it teaches the very minimum. Which by design is not bad. But many people I have met tend to think what they read is the definitive authority. They measure their abilty to these printed standards, so by following them literally, they believe they are doing the best job possible. (you will see the same of ACLS, PALS, and NRP providers, but it still doesn't make them experts in the respective fields)
   
  I was trying to illustrate the point, in my experience, that trauma experts, partcularly surgeons, really don't spend much time educating people to trauma. You don't have to teach EMs how to operate But it helps to tell them what the next steps are so everyone is on the same page, working towards the same goal. (for some reason smart people don't like 1 word answers, so "the goal is surgery" is not only not enough, but not always true)
   
  I was very fortunate to work at a incredible level I center. Obviously if you are a trauma patient and wind up there you are in great hands, not only because of the system but the people too. However, unless you live in the downtown area, it is not your first stop. Many trauma patients outside the immediate range of these ivory towers wind up at centers which are clearly not as capable as the dedicated hospitals for a variety of reasons, possibly for an hour or longer. I am not defending it, just accepting the fact. Surely we would not just advocate calling for transfer and sit on your hands? It seems a lot of the problems stem not from overstepping scope, but from different perspectives and lack of resources. In the ideal world no patient would ever arrive at a center that was not specialized in the field of their illness.(with practicioners dedicated to such) If I may entertain you with another quote from a former teacher of mine: "The book demonstrates the ideal
 circumstances in which to effect a rescue. If the circumstances were ideal, nobody would need rescuing."
   
   We should make every effort to recognize there will always patients be taken to places that are not centers of trauma excellence first. They still can be improved to make a positive impact. I think education and regular involvement is the best way. 
  You will never hear me say that a seriously injured person needs anything other than a surgeon. But unfortunately, in the US at least, they may not get one right away. So the task of caring for them falls on the Emergency physician, PA, paramedic, etc. because the alternative is the patient receives no care at all. 
   
  I would venture that the improvement of trauma care around the world rests not only with the techniques and constantly updated knowledge available to practicioners, but to the larger circle that starts with the P word (prevention) and takes into account every step in today's system up to reintergration into as close to pre-injury life as possible. Let us always see the forest from the trees.
   
  I'll end with a favorite quote of mine from Sun Tzu
  "Strategy without tactics is the slowest route to victory. Tactics without strategy is simply the noise before defeat."
   
  Mike
   
  P.S. in response to finding interested people. Plug for me: In a few years when this med school thing is done, if anyone would like an old paramedic hell bent on a trauma surg career , I do nights, weekends, and holidays, low pay/long hours the norm, and 9-5 lifestyle not expected or wanted. (Would like an ivory tower though)


   
  No matter how skilled, I've never met an ED physician who can
therapeutically open a chest or remove a spleen. If you are having
problems finding surgeons to care for your critically injured patient
then you shouldn't be in the business of taking care of the critically
injured. That's why ATLS exists: To teach those who don't take care of
the critically injured on a regular basis the minimum skills to get a
patient stable to TRANSFER to a trauma center PERIOD. ATLS doesn't make
you qualified to care for patients more than just the bare minimum to
effectively make decisions on disposition and initial treatment. No one
should think otherwise.

This "apathy" that you describe really doesn't exist at a level 1 trauma
center. There are problems getting surgical residents interested in
careers in trauma, but for those surgeons already working it's not an
issue. I can't speak for level II or level III trauma centers as the
bulk of that call is (by the best available data) private surgeons. But
newer models of surgical hospitalists as acute care surgeons, surgeons
who focus on care for the critically injured and respond to all surgical
emergencies within the hospital are fast being shown to be profitable,
professionally appealing and more in keeping with a better lifestyle
than what has been for the surgeon traditionally.

Ben Reynolds, PA-C
Pittsburgh, PA








----- Original Message ----
From: "Moore, Rick" 
To: "Trauma & Critical Care mailing list" 
Sent: Friday, February 1, 2008 9:03:33 AM
Subject: RE: Operating Room Resuscitations

Finally someone who lives in the real world!! 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Mike Smertka
Sent: Thursday, January 31, 2008 6:07 PM
To: Trauma &, Critical Care mailing list
Subject: Re: Operating Room Resuscitations


Just from reading this forum for a while I think the EM may have
overgrown the trauma role because surgery is not always readily willing
or available. I have seen where it has taken 45+ minutes for a surgeon
to wander down to the ED. (A&E) Not too long ago on this forum there was
a discussion of how to get surgeons to take trauma call. It seems
logical the ED would grow beyond their traditional role when they could
not rely on somebody else. I assume all of the surgeons here are
interested in trauma, and do not suffer from such apathy responding to a
trauma page. But even in designated "trauma" centers (in my experience
level IIIs) surgery just doesn't show up in time to be much help (if at
all). Figure: If you get a trauma page, you have no interest in trauma
and work in a community facility, if you delay your response, there is
high likelyhood the ER physician will initiate a transfer. So if The ED
gets a patient, it takes 1/2 hour to assess, stabilize and even get the
transport going, another 10-20 minutes for a helicopter or a ground
unit, it seems reasonable an EM will be taking care of them for the
better part of an hour. 

Obviously in a specialized trauma center the idea of a critical
patient in the ED so long sounds insane. But I think sometimes trauma
specialists are their own worst enemy. I have never met a trauma surgeon
in person who takes a regular interest in prehospital education or
activities. I have never met one in person who shows up to the ED
meetings. So when there is talk of what equipment to buy/need, or
protocol on what to do, etc. the major player is missing, so the ED does
what it thinks is right. Take it one step further, how long has it been
since anyone here has argued the merits of rapidly infused chrystalloid?
But on page 76 of 7th edition ATLS: it states that bleeding from
external wounds is usually controlled by direct pressure..... and that a
PASG should not delay fluid therapy and surgery may be needed. (lets
face it, that sounds like the priority is fluid, not surgery) on the
very next page in bold print: "initial warmed fluid given as rapidly as
possible..."
it then gives the dose and finishes with "This often requires pumping
devices (mechanical or manual) to fluid administration sets." Is it a
wonder there are a bunch of rapid infusers, or prolonged ED time trying
to get an IV line?

The last time I attended ATLS, the course director (whom I hope to
someday be as skilled and knowledgable as) opened with the phrase : "I
am not here to teach you how to take care of a trauma patient." So if
trauma experts don't teach that, how do nonexperts who are in the chain
learn? Moreover, he raised the point "If you cannot close a chest,
please do not open it." I think a very valid point, because if you let
EMs open the chest and they have no access to a surgeon or ICU that can
deal with the aftermath, what has really been done? I won't even start
on BTLS or ITLS. But also consider: If EMs are the ones teaching
prehospital providers, what you constantly teach, you ingrain in your
own brain. The overall goal then becomes getting to a doctor at the
hospital. which to prehospital means the ED. Ths also doesn't touch on
places where the amount of resources the ED has, far outstrips the ICU.
Obviously there is no substitute for an OR, but what is the surge
capacity of an OR or ICU compared to the surge capacity of an ED? I
figure they are different in different places, so no one system could
possibly be "better."

I focused the discussion on trauma, but I don't see other critical
illnesses as any different for this.

once agan thanks for listening to my musings. I am not trying to take
sides, but to bring sides together.

Mike 


EM has an important role to play in every hospital, but how much should
they paly in major trauma or critical illness? Has the role of EM grown
too far beyond immediate care?

Regards
Mark F
UK




----- Original Message ----
From: Matthew Reeds
To: trauma-list at trauma.org
Sent: Thursday, 31 January, 2008 12:05:49 PM
Subject: Operating Room Resuscitations


I agree Errington. I would in fact go further by saying that the ICU/HDU
is THE ONLY place for patients who need resuscitation but DON'T need the
operating room (unless they are going to interventional radiology for
embolisation etc.) Further to Ken's comment on the role of the A&E/ED
department "waving to the patient", this I fully agree with and
wholeheartedly support.
However I would say that the A&E does actually have ONE useful purpose -
for the receptionist to book the patient into the hospital. They can
also ensure that the order for massive transfusion packs is made
IMMEDIATELY for them to be sent STRAIGHT to theatre/OR for the patient
(for those hospitals that implement the 1:1 transfusion protocol.) I'll
happily conceed that this is in fact two purposes.
Matthew
____________________________________________________________
KMATTOX at aol.com KMATTOX at aol.com
Thu Jan 31 03:26:29 GMT
BINGO. Great point. For any trauma patient that is not going to be able
to be dismissed from the ER following minor treatment for a minor
injury, there is NO REASON TO KEEP THAT PATIENT IN THE ER ANY LONGER
THAN IT TAKES TO COMPLETE THE LOGISTICS OR PAPERWORK TO GET THEM TO THE
OR, ICU, FLOOR, IR, OR OTHER LOCATION. 

Kenneth L. Mattox, MD
Houston


In a message dated 1/30/2008 9:23:48 P.M. Central Standard Time,
errington at erringtonthompson.com writes:

The ICU is a great place for patients who need resuscitation but DON'T
need the operating room. 

E
____________________________________________________________
In a message dated 1/30/2008 9:23:48 P.M. Central Standard Time,
errington at erringtonthompson.com writes:
I would add that those patient that don't need to go to the OR but still
need significant resuscitation maybe better in the ICU than the ER or
anywhere else. For the most part trauma surgeons run their own ICU's.
These are the nurses that have heard your lectures. They come to your
conferences. They know what you want. 

The ICU is a great place for patients who need resuscitation but DON'T
need the operating room. 

E

Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Author - Letter to America
Asheville, NC

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at
trauma.org] On Behalf Of Ronald Gross
Sent: Wednesday, January 30, 2008 6:52 AM
To: trauma-list at trauma.org
Subject: Re: Operating Room Resuscitations

Yeah - what HE said! ;-)

Matt, you and I are on the same page here - but you said it far better
than I did - Thanks!

Take care,
Ron

>>> Matthew Reeds 1/30/2008 5:27 AM >>>

Mike & Ron,
When pontificating over the treatment that I give to any patient, I
always try to ask what I would want for myself and apply this to give
the best treatment to each patient. I would NOT want to be in an A&E/ED
resuscitation room but would "rather" be in either theatre/OR, ITU/HDU,
the ward or radiology (depending upon my injury) having the proper
treatment that I need. This is what I would strive for with any of my
patients.
Therefore I see NO reason for the patient to remain in A&E/ED for
resuscitation. As Ron says, if the patient needs surgery, then off to
theatre/OR they go. If they need non-operative resuscitation, then off
to ITU or HDU they go for the care required. [This frees up theatre/OR
resources and time as Mike says if surgery is not required for better
utilisation.] Radiology resuscitation is ONLY required for THERAPEUTIC
intervention such as angio for pelvic haemorrhage and stabilisation (if
the extra-peritoneal pelvic packing approach is NOT used etc.)
>From my experience, there is NO need/role for A&E/ED resuscitation - if
the
patient is that sick, then they need to be elsewhere (e.g. theatre/OR,
ITU/HDU etc.) Even for major haemorrhage that requires surgery, these
UNSTABLE patients SHOULD be rapidly transported to theatre/OR for
surgery for emergency treatment. I would NOT NORMALLY advocate A&E/ED
operating UNLESS absolutely necessary which has happened to me on a
couple of occasions [such as cardiac arrest secondary to IVC transection
at the bifurcation from multiple stab wounds from a bayonet in a 19 year
old male.] He had been "down" for 3 mins when he arrived in A&E by
paramedics/EMT and there was no way we could transfer him to theatre/OR
on the top floor (11th floor) and at the other end of the hospital to
save him - a fault of the hospital design.
Therefore
we performed a laparotomy in the A&E/ED resus room and got him back with
RAPID abdominal packing and then transferred to theatre just as rapidly.
However, this should be a RARE occasion and ONLY be absolutely necessary
to imminently save life rather than be the norm. In essence this comes
down to clinical acumen, experience and ability of the clinician to use
sound judgment and I agree with Mike, that if the patient doesn't need
surgery, then theatre/OR is not the best place to resuscitate the
patient - they should be in the ITU/HDU instead.

Matthew
Surgery U.K.
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